2024 Volume 31 Issue 6 Pages 953-963
Aim: Hypertensive disorders of pregnancy (HDP) are among the obstetric complications reportedly associated with later-life cardiovascular disease (CVD). This study examined physicians’ recognition of reproductive history by elucidating their attitude and knowledge.
Methods: This study included council members of the Japan Atherosclerosis Society. An Internet-based survey was conducted between August 9 and September 9, 2022.
Results: A total of 137 council members completed the questionnaire (response rate: 36%). In terms of the internal medicine subspeciality of the participants, endocrinology was the most common (46%), followed by cardiology (38%). About 70% of the participants considered reproductive history to be important and obtained more information than those who considered it otherwise. In the questionnaire for knowledge about HDP and future diseases, physicians correctly answered 6.8 of 9 questions. Endocrinologists were more likely to ask regarding reproductive history at the initial visit than cardiologists (82.5% vs. 61.5%; p=0.012) and obtained more information from women below 50 years old. Contrarily, cardiologists obtained information on reproductive history from older women (those approaching menopause and those in their 60s and 70s).
Conclusion: We found that physicians had a high level of knowledge about HDP and the importance of reproductive information. However, the manner of obtaining information, including the target population, differed depending on the subspeciality. In the future, effective interventions for women with a history of HDP need to be developed in order to encourage physicians to obtain reproductive information to prevent CVD.
Hypertensive disorders of pregnancy (HDP) are estimated to occur in up to 8% of all pregnancies. HDP are characterized by the presence of hypertension during pregnancy1). They are diagnosed when hypertension is first observed after 20 weeks of gestation. However, newly pregnant women with chronic hypertension have also been defined as HDP. These women are commonly identified by physicians specializing in internal medicine. Although this obstetric complication can substantially affect the morbidity and mortality of the mother and child, in most cases, blood pressure returns to normal levels within 12 weeks after termination of pregnancy. However, HDP can have an impact on the long-term prognosis of women2-3). Several studies from abroad have reported an association between a history of HDP and the risk of cardiovascular disease (CVD). In our previous study, based on the database of residents released by the Tohoku Medical Megabank Organization, the risk of CVD was higher in women who had a history of HDP and hypertension4).
This type of information on HDP and future CVD risk is not appropriately used5-6). Generally, perinatal care provided by obstetricians ends at 1 month postpartum, and a clinical follow-up program for obstetric complications (e.g., HDP) is not established. Thus, physicians need to be diligent in obtaining complete record of patients’ reproductive history.
This study aimed to explore physicians’ recognition of the interaction between HDP and CVD and to examine their reproductive history-taking. This would help elucidate their attitude and knowledge toward reproductive information.
The questionnaire comprised three sections, all of which are presented in Tables 1 and 2. The first section consisted of demographic data (sex, years of experience, area of specialization, and place of work [Q1–4 of Table 1]). The second section consisted of questions regarding the handling of and viewpoints toward reproductive histories (Q5–12 of Table 1; also see Figs.1, 2, and 3). Reproductive history-taking was defined as whether the physicians asked about the 14 items shown in Q5 of Table 1 when they first saw a female patient or after multiple visits. The third section consisted of five questions regarding HDP (specifically the association between a history of HDP and future CVD) for assessing physicians’ knowledge about HDP (Q1–5 of Table 2). Q1–3 had true–false responses, whereas Q4–5 required physicians to choose the answer that they believed was correct. All the items listed were drawn from current literature or recommendations. The questionnaire was developed by experts (cardiologists, obstetricians, and a psychologist), and the questions were tested by several physicians to confirm whether the intent was correctly conveyed and there were no questions with extremely low or high percentages of correct answers.
| 1. Demographic data of physicians |
|
Q1. How many years of experience do you have as a physician? (Select one) Up to 10 years / 11-20 years / 21-30 years / More than 30 years / Do not want to answer / Other |
|
Q2. What is your gender? (Select one) Male / Female / Do not want to answer / Other |
|
Q3. What is your subspeciality as a physician? (Select one) General internal medicine / Cardiology / Endocrinology / Neurology / Do not want to answer / Other |
|
Q4. What is your workplace? (Select one) Clinic / General hospital / University hospital / Health-checkup center / Do not want to answer / Other |
| 2. Handling and viewpoints of reproductive histories |
|
Q5. Please select the information you obtain from female patients at the initial visit. (multiple answers allowed) 1. Presence or absence of delivery / 2. Number of deliveries / 3. Presence or absence of pregnancy / 4. Number of pregnancies / 5. Presence or absence of children / 6. Number of children / 7. Miscarriage experience / 8. Number of miscarriages / 9. Stillbirth experience / 10. Number of stillbirths / 11. Experience of obstetric complications such as HDP and GDM / 12. Infertility experience / 13. Not asked / 14. Other |
|
Q6. Please select the information you obtain from female patients after multiple visits. Same choices as Q5 |
| Q7-9. From which population do you typically obtain a reproductive history? |
|
Q7. Select the age group (multiple answers allowed) 10s / 20s / 30s / 40s / 50s / 60s / 70s / regardless of age / Not asked / Other |
|
Q8. Select the status (multiple answers allowed) Possibility of future pregnancy / Women who are pregnant / Women around menopause Women who had completed childbirth / Not asked / Other |
|
Q9. Select disease under treatment (multiple answers allowed) Diabetes mellitus / Hypertension / Dyslipidemia / Not asked / Other |
| Q10. How important is reproductive history of female patients to you? Choose from "very important" to "not important" (5-point scale) |
|
Q11. Do you ever change your policy of medical practice based on reproductive history? Choose from "often" to "never" (5-point scale) |
|
Q12. Do you find it difficult to take female patients’ reproductive history? Choose from "very difficult" to "easy" (5-point scale) |
| 1. Questions about HDP | ||
|---|---|---|
| Choose whether you think these statements are correct or incorrect | Correct answers (%) | |
| Q1. HDP occurs in 1% of all pregnancies | incorrect | 51.1 |
| Q2. The incidence rate of HDP in Japan is gradually declining | incorrect | 93.4 |
| Q3. Genetic factors are associated with HDP development | correct | 91.2 |
| Choose the correct item(s) | ||
| Q4. Risk factors for the development of HDP. |
Average score (range) 3.9 (2-5) |
|
| Advanced maternal age | correct | |
| Obesity | correct | |
| Family history of hypertension | correct | |
| Multiparas | incorrect | |
| Egg donation | correct | |
| Q5. Diseases that carry a high risk of development in the future in women with a history of HDP. |
Average score (range) 6.8 (4-9) |
|
| Myocardial infarction | correct | |
| Cerebral infarction | correct | |
| Diabetes mellitus | correct | |
| Dyslipidemia | correct | |
| Chronic kidney disease | correct | |
| Dementia | correct | |
| Ovarian cancer | incorrect | |
| Endometrial cancer | incorrect | |
| Breast cancer | incorrect | |
Physicians (n=137) were asked to select items of information they obtained from female patients on their first visit and after multiple visits. These 14 items are presented in Q5 of Table 1. Black bars indicate the percentage of physicians who ask for those items on the first visit, and dotted bars indicate the percentage of physicians who ask after multiple visits.
Note: Multiple answers were allowed.
Physicians’ answers to Q7, Q8, and Q9 of Table 1 were summarized as A (Q7), B (Q8), and C (Q9), respectively. The bars show the percentage of physicians who chose that option.
Note: Multiple answers were allowed.
Physicians selected the best answer to each question using a five-point Likert scale. The graph presents the percentage of physicians who chose each option.
This study included council members of the Japan Atherosclerosis Society. The study protocol was approved by the Research Ethics Committee of the Japan Atherosclerosis Society (202201) and Medical Research Ethics Committee of Tokyo Medical and Dental University (M2022-122). A document describing the purpose of the study was emailed to all council members. Then, a link to an Internet-based survey was sent to those whose willingness to participate had been confirmed via e-mail. The responses to the questionnaire were collected using an anonymous Internet-based program between August 9 and September 9, 2022. No incentives were given to the participants for their participation.
3.3 Data AnalysesThis survey was designed using a mixed method. First, descriptive statistics (median, range, and percentage) were calculated for demographic information. Second, the frequency of responses regarding history-taking or attitude toward reproductive history was counted for each question choice and expressed as a percentage. Physicians were also allowed to add any other items that were not in the list. Finally, physicians’ knowledge about HDP was assessed. For Q1–3, one point was given for correct answers and zero for the wrong answer. Q4 consisted of five items and Q5 nine items. Thus, if all the correct answers were chosen, Q4 would give five points and Q5 nine points. Statistical analyses were conducted using SPSS 26.0 (IBM, Armonk, NY, USA). p＜0.05 (two-sided) was considered to indicate statistical significance.
A total of 137 council members completed the questionnaire (response rate: 36%). Of the participants, 91% were men and 51% reported having 21–30 years of experience as a physician (Table 3). With regard to the subspecialities of internal medicine, endocrinology was the most common (46%), followed by cardiology (38%). University and general hospitals accounted for 88% of the workplaces of physicians.
| Variable | Number of respondents (n) | % |
|---|---|---|
| Gender | ||
| Male | 125 | 91.2 |
| Female | 12 | 8.8 |
| Prefer not to answer | 0 | 0 |
| Years of experience as a physician | ||
| ≦10 | 0 | 0 |
| 11-20 | 14 | 10.2 |
| 21-30 | 70 | 51.1 |
| ≧31 | 53 | 38.7 |
| Other | 0 | 0 |
| Subspeciality as a physician | ||
| General Internal Medicine | 14 | 10.2 |
| Cardiology | 52 | 38.0 |
| Endocrinology | 63 | 46.0 |
| Neurology | 2 | 1.5 |
| Other | 6 | 4.4 |
| Type of workplace | ||
| Clinic | 10 | 7.3 |
| General hospital | 23 | 16.8 |
| University hospital | 98 | 71.5 |
| Health-checkup center | 0 | 0 |
| Other | 6 | 4.4 |
Physicians were asked to select from 14 items (presented in Q5 in Table 1) regarding history-taking related to pregnancy and childbirth that they took when women consulted them for the first time (multiple answers were allowed). Fig.1 presents the percentage of physicians who chose each of the 14 items for first visits and after multiple visits. The most common question asked by physicians was related to the “presence or absence of children,” followed by the “presence or absence of delivery,” “number of children,” and “experience of obstetric complications.” In general, the percentage of physicians who chose these questions did not increase after multiple visits of female patients. Furthermore, items such as “miscarriage,” “stillbirth,” and “infertility” were not asked during the first visits or after multiple visits.
Next, to further elucidate the detail of the history-taking, we asked about the background of the patients. The most frequently selected age group was 30 to 40 years (Fig.2). The “possibility of future pregnancy” and “having diabetes mellitus” were the most frequently selected status.
Regarding the importance of reproductive history, 70% of the participants answered “very important” or “somewhat important,” and 59% answered that they “often” or “sometimes” changed their policy of medical practice based on reproductive history (Fig.3). Based on the total number of items selected by physicians from those presented in Q5, Table 1, those who answered that reproductive history was important obtained more information than those who answered neither or not important (“very important” or “somewhat important” vs. “neither” vs. “not very important” or “not important”; 5.8±0.5 vs. 3.7±0.5 vs. 1.3±0.4; p=0.0002). Those who answered that they changed their policy of medical practice based on reproductive history obtained more information than those who answered otherwise (“often happens” or “sometimes happens” vs. “neither” vs. “never” or “almost never”; 5.9±0.6 vs. 4.3±0.7 vs. 2.6±0.5; p=0.003). Of the participants, 41% answered that the reproductive history-taking was “very difficult” or “somewhat difficult” (the bottom bar of Fig.3). When we compared the results of the difficulty of history-taking (Q12) and the number of items of reproductive history-taking (Q5), no association was observed between the two.
4.3 Knowledge of HDP among PhysiciansTable 2 presents the percentage of correct answers and average score toward knowledge questions concerning HDP. The average score was 13.1 points (range: 8–17). Most participants knew that the prevalence of HDP in Japan was not declining (Q2) and that genetic factors were associated with the development of HDP (Q3). They correctly answered 6.8 out of 9 questions regarding the subsequent diseases after HDP (Q5). We compared the demographic data of physicians (Q1–4, Table 1) with the total score for Q1–5 and physicians’ views on reproductive history (Q10–11, Table 1) and found no correlation between the score and the demographics of the participants (e.g., number of years of experience as a physician, sex, subspeciality, and type of workplace) nor the recognition of participants (e.g., degree of importance of reproductive history or impact on their policy of medical practice).
4.4 Characteristics of Endocrinologists and CardiologistsNext, we focused on endocrinologists and cardiologists who accounted for 84% of the respondents of our questionnaire. We compared the number of items from Q5 obtained by each of these two groups of physicians and found that endocrinologists obtained significantly more information (5.94±5.1 vs. 3.85±4.35; p=0.021). Furthermore, they obtained higher score for knowledge (13.52±1.80 vs. 12.88±1.90; p=0.066) (Table 4A).
| Endocrinologists | Cardiologists | p | ||
|---|---|---|---|---|
| Total number of items obtained from Q5 | number | 5.94 | 3.85 | 0.021＊ |
| SE | (0.64) | (0.60) | ||
| Knowledge scores | points | 13.52 | 12.88 | 0.066† |
| SE | (0.23) | (0.26) |
Abbreviation: SE, standard error.
＊p＜0.05 †significant trend
Interestingly, the endocrinologists’ and cardiologists’ scores for knowledge were not correlated with their responses toward the importance of reproductive history, its impact on their policy of medical practice, or the ease of history-taking. The number of items from Q5 obtained tended to be higher for both endocrinologists and cardiologists who answered that “information about reproductive history was important” and that they “would change their policy of medical practice based on reproductive history” (Table 4B).
| Importance of reproductive history | ||||
| Very / somewhat important | Neither | Not very / not important | p | |
| Endocrinologists | 6.76 | 3.57 | 0.80 | |
| (0.73) | (0.75) | (0.49) | 0.016＊ | |
| Cardiologists | 4.57 | 3.67 | 0.88 | |
| (0.83) | (0.88) | (0.35) | 0.093† | |
| Changes in polycy of medical practice based on reproductive history | ||||
| Often / sometimes | Neither | Almost never / never | p | |
| Endocrinologists | 6.81 | 5.56 | 3.17 | |
| (0.84) | (1.22) | (1.07) | 0.088† | |
| Cardiologists | 4.76 | 3.11 | 1.11 | |
| (0.84) | (0.89) | (0.39) | 0.067† | |
Numbers in parentheses indicate SE
＊p＜0.05 †significant trend
Endocrinologists were more likely to take reproductive history at the first visit than cardiologists (82.5% vs. 61.5%; p=0.012). The ease of history-taking was correlated with the number of items obtained by cardiologists (“very difficult” or “somewhat difficult” vs. “easy” or “somewhat easy” vs. “neither”; 5.7±1.2 vs. 2.9±1.3 vs. 2.2±0.5; p=0.097): this correlation was not observed among endocrinologists.
Endocrinologists obtained significantly more information on reproductive history (items from Q5) from “women with a possibility of future pregnancy” (6.51±5.28 vs. 4.33±4.57; p=0.049) and “women who are pregnant” (6.98±5.21 vs. 4.58±4.88; p=0.044) compared with cardiologists. Conversely, cardiologists who took reproductive history from “women around the time of menopause” (6.82±1.44) and “women who had completed childbirth” (7.15±1.94) obtained more information than those took reproductive history from “women with a possibility of future pregnancy” (4.33±0.76) and “women who are pregnant” (4.58±0.88). Similarly, endocrinologists obtained significantly more information from female patients aged below 40 years or who were in their 40s to 50s than cardiologists. This difference disappeared when women were in their 60s (Fig.4).
To compare cardiologists’ (black bar) and endocrinologists’ (dotted bar) attitudes toward female patients, this graph shows the number of items of information obtained by each of those two groups from particular populations of women.
＊p＜0.05, †p＜0.10. Error bars reflect 1 SE.
Note: Multiple answers were allowed.
About 70% of the study participants considered the reproductive history of women to be important. The average score in our HDP questionnaire was 70%. The question regarding the relationship between HDP and future CVD (which was the main objective of our study) was correctly answered, with an average score of 75% (6.8 out of 9.0 points). Differences were observed in the knowledge score and amount of information obtained according to subspecialty. Endocrinologists had a higher score for knowledge and obtained more information on reproductive history than cardiologists. In particular, endocrinologists obtained more information on reproductive history from women aged below 30 years and those in their 30s and 40s in the initial visits. Contrarily, cardiologists obtained information on reproductive history from older women (those approaching menopause and those in their 60s and 70s). This difference may occur because endocrinologists see gestational diabetes in younger women, whereas cardiologists see older women who are at a high risk of heart disease. In any case, it is important to share reproductive information across different departments for the lifelong medical health management of women.
5.2 Risk Factors of CVD Associated with Pregnancy and ChildbirthIn Japan, the number of deaths due to CVD has continued to increase for the past four decades and CVD is considered as the second largest cause of death among women. Cerebrovascular disease and cardiac disease account for 20% of the causes of a need for long-term care7). To reduce healthcare costs and extend healthy life expectancy, eradication of CVD is an important issue in Japan.
The risk factors for HDP development include hypertension, diabetes mellitus, obesity, and advanced maternal age8-10). In recent years, the number of births in Japan has been declining year by year and the number of births to advanced-aged women has increased, currently accounting for one-third of all births11). Thus, pregnancy-induced hypertension and pregnancy with chronic hypertension have been considered as emerging pathological conditions newly included in HDP in 2018 12). Though advanced medical interventions successfully reduced the risk of death from HDP, the prognosis impact of HDP is increasing.
Japanese women have long life expectancy, but there is a gap of more than one decade between life expectancy and healthy life expectancy11). Hence, it is crucial for women to know their own CVD risk through pregnancy and childbirth experience in their 30s and 40s. To address this issue, we recommend the following. First, obstetricians should explain the long-term effect of CVD risk to postpartum women with a history of HDP. For this purpose, written materials are effective not only as a current reminder but also as a recall to trigger in the future. Second, women should be aware of their risk and create a health-checkup plan actively. Third, physicians should take reproductive history and use it in their practice (e.g., consider an early intervention for women with hypertension if they have a history of HDP). In fact, physicians were the most frequently selected healthcare provider for women with a history of HDP in this survey (69%). Furthermore, many women feel embarrassed or feel it is unnecessary to talk to their physicians regarding their reproductive history; thus, physicians should be encouraged to ask about it5).
Clinical guidelines on HDP are available in Europe and the USA, but recommendations for HDP follow-up in Japan are lacking. Table 5 presents the recommendations for HDP follow-up from representative guidelines abroad13-17). These guidelines provide much evidence of an association between HDP and later-life CVD risk. Contrarily, the appropriate timing of effective interventions has not been defined and must be elucidated in future studies. Moreover, there is evidence from abroad suggesting that an adverse pregnancy outcome (APO), e.g., miscarriage, stillbirth, or infertility, can generally influence future CVD in women18). The American College of Obstetricians and Gynecologists (ACOG) has recently called the postpartum period the “fourth trimester” and described it as an important time to provide patient education to reduce long-term CVD risk among women with APOs14). The American Heart Association and ACOG also encourage cardiologists and obstetrician/gynecologists (OB/GYNs) to collaborate to reduce CVD risk in women19). In this advisory, APOs such as HDP are considered as sex-specific CVD risks. Cardiologists and OB/GYNs are recommended to collaborate to collect comprehensive medical history information. The incidence of CVD is lower in Japanese women than in women from other developed countries, but it would still be beneficial to explore the potential contribution of APOs, such as HDP, in Japan and to perform full reproductive history-taking including APOs.
| AHA13) | ACOG14, 15) | ESC16, 17) | |
|---|---|---|---|
| Type of obstetric conditions |
pre-eclampsia Pregnancy-induced hypertension |
Hypertensive disorders of pregnancy |
pre-eclampsia Pregnancy-related hypertension |
| Recommended follow-up |
|
|
|
Abbreviations: AHA, American Heart Association; ACOG, American college of Obstetricians and Gynecologists; ESC, European Society of Cardiology; CVD, cardiovascular disease; BP, blood pressure.
Our study had three main limitations. First, the results may not be generalizable to all physicians. Second, the response to our questionnaire was sufficient for analyses; however, the targets were council members, many of whom were working at university hospitals and only a few at clinics or health-checkup centers. The awareness of physicians working in clinics or health-checkup centers is important in disseminating information and prevention; thus, a survey including these venues might have produced different results. Third, the subspecialities of endocrinology and cardiology accounted for 84% of the total participants, so selection bias is possible. The relationship between the level of knowledge about HDP and practice needs to be investigated further.
Physicians and obstetricians can collaborate to assess the lifetime CVD risk of a woman and thereby reduce it. In the future, associations between HDP and later-life CVD need to be described in Japanese guideline and effective interventions for women with a history of HDP should be elucidated to encourage physicians to obtain reproductive information in order to prevent CVD. Furthermore, current research on heart disease has been conducted mainly on men. Hence, it is also important to focus on the differences between men and women with respect to heart disease in order to provide necessary information so as to prevent CVD in women.
This research was supported in part by a grant from the Japan Atherosclerosis Research Foundation and the Japan Ministry of Health, Labor, and Welfare (23K08860).
None.
